Employee Illness Form (for Infection Control)
Employee's Name
*
First Name
Last Name
Date of illness:
*
-
Month
-
Day
Year
Date Picker Icon
Date last worked:
*
-
Month
-
Day
Year
Date Picker Icon
Area last worked (House):
*
Please Select
Courage
Freedom
Honor
Peace
Victory
Valor
Legacy
Liberty
Hero
Independence
Office worker
Symptoms of illness check all that apply:
*
Sore Throat
Fever
Cough
Runny or stuffy Nose
Body Aches
Headache
Chills
Fatigue
Diarrhea
Vomiting
Other
Has the Employee tested positive for a contagious illness?
*
Yes
No
What was the illness?
*
Submit
Should be Empty: